306005334-9-20-2024-22-AS-KSGH-D9ARR5-20240920131435

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005334
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:15:50 PM

Document Has Been Signed on 09/20/2024 01:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	WONDER'S YEARS		FACILITY NUMBER:	306005334
ADMINISTRATOR:	JUAN M. GARCIA TRUJILLO		FACILITY TYPE:	740
ADDRESS:	24301 BARK STREET		TELEPHONE:	(949) 215-4087
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 4	DATE:	09/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Juan Trujillo, Administrator		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility administrator Juan Garcia Trujillo staff after introducing himself and stating the reason of the visit. During the inspection, LPA and staff conducted a tour of the physical plant and observed the following: The facility is a two-story home with two shared bedrooms and one private room in addition to the facility's common living areas and one attached garage. The second level of the house is for use by staff exclusively. There are two bathrooms including one en-suite bathroom. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linen and blankets. One bed is observed to be equipped with full rails. Physician order and hospice plan of care reviewed.. There are currently four residents admitted to the facility, one of which is receiving hospice care. Bathrooms faucets and toilets are operational. Water temperature was measured to be approximately 110F. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed. Drills are conducted quarterly, they are however not documented. Consultation provided on Technical Assistance Advisory Note. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is fully charged and has been maintained in 2024. There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the property. The routes of egress are free of obstructions. There is an adequately fenced empty swimming pool on the premises. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WONDER'S YEARS	FACILITY NUMBER: 306005334
	VISIT DATE: 09/20/2024

NARRATIVE

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CONTINUED FROM FORM LIC809
Licensee plans to have the pool covered and is intending to obtain building permits from the city of Lake Forest. LPA informed licensee to provide modified floor plans and building permits to the Department.

Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders. The record of centrally stored medication dosages is however found to be outdated for two out of four residents. A type B deficiency is cited on an attached form LIC809-D.

LPA reviewed four resident files and two staff files. One staff and two resident interviews conducted. Resident records include all necessary components. All staff members are confirmed to be cleared and associated with this particular licensed location. Training records are however missing for 2024. One staff member does not meet the annual requirement of 20 hours of training. A type B deficiency is cited on an attached form LIC809-D. CPR training on file and up-to-date. The poster for reporting information is observed to be posted but smaller than the required size. Technical Assistance Advisory Note provided. Infection Control Plan is not using the Department-issued for. Technical Assistance and copy of form LIC 9252 provided.

Based on the observations made during today’s inspection, two type B deficiency are being cited per Title 22 Division 6 of the California Code of Regulations. Three Technical Assistance Advisory Notes are also provided along with related consultations to the licensee.

An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2024 01:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WONDER'S YEARS	FACILITY NUMBER: 306005334
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff records reviewed , the licensee did not comply with the section cited above as one staff member had documented training which did not meet the mandatory 20 hours of annual training in 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2024
	Plan of Correction
1 2 3 4	Licensee will provide annual training to relevant staff and provide proof of completion to LPA before the plan of corrections due date.

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records reviewed, the licensee did not comply with the section cited above as the centrally stored medication in place did not match prescription lists on file for two out of four residents.This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Licensee will updated the Medication Administration Records to reflect the current prescriptions and provide proof thereof to LPA before the Plan of Corrections due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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